Selective Dorsal Rhizotomy (SDR) at St. Louis Children's Hospital
This is a brief review of selective dorsal rhizotomy offered at our center. From this information, you will learn more about not only selective dorsal rhizotomy, but also other currently available treatments for spastic cerebral palsy. You'll also learn about what happens during hospitalization after selective dorsal rhizotomy surgery. In spastic cerebral palsy there are three major problems: motor impairment, spasticity, and deformities of the lower extremities. Motor weakness is the essential part a cerebal palsy. Because a motor weakness, patients have difficulty sitting, standing, walking and other activities. Spasticity if once present in early childhood does not disappear without treatment. It makes muscle stiff, interferes with walking, and other movements and adversely affects growth of muscles, bones, and joints.
Patients with cerebral palsy are not born with deformities such as tight hamstrings and heal chords. Rather, they develop deformities as they grow Spasticity and motor impairments both contribute to the development of deformities. Finally, deformities that are caused by motor weakness in spasticity further impair motor function. Also if motor impairment persists, more deformities develop.
From the slide, one can tell that if spasticity is reduced at a young age, deformities become less severe. It is important to know that there is no benefit to living with spasticity. Because of the known harmful effects of spasticity, a number of current treatments are used. They are: physical therapy in braces, oral medications, Botox injections, orthopedic surgery, baclofen pump, and selective dorsal rhizotomy. Physical therapy is well known to you We believe that physical therapy can help reduce orthopedic deformities and help children learn motor skills. Several medications such as baclofen by mouth are used but the beneficial effects of these are all medications are still unclear.
Also, we are concerned about the side effects of Medicine on the child's growing brain. For these reasons, our center does not favor the use of oral medicines. Botox has become popular in the past several years. Botox is frequently injected into a few muscles of the legs. It can reduce spasticity he by weakening muscles temporarily. Although the beneficial effects are often obvious, the main disadvantage is that the effect lasts for only two to three months and repeated injections result in weakening of the muscle overtime. Muscle and tendon releases are often used. The orthopedic surgeries can improve joint range of movement, sitting and walking.
Orthopedic surgery is the best choice for fixed deformities. However, there are significant disadvantages associated with traditional muscle tendon lengthening, including permanent weakness of length in muscles, risk of over lengthening and the surgery often needs to be repeated as children grow. It is important to know that muscle and tendon releases do not address a root problem of spastic cerebral palsy, namely spasticity. Rather it addresses the result of prolong spasticity.
Percutaneous muscle tendon surgery is a conservative approach to muscle lengthening it is done through a small opening in the skin where a controlled lengthening is performed. There is significantly less risk of overlengthening the muscle with this technique. Patients require no casting and in most cases, no hospital stay. Patients are indicated for this procedure only after an evaluation by both Doctor Dobbs and Doctor Park. We recommend the "Percs" only after dorsal rhizotomy surgery. For Baclofen infusion, a pump is placed in the abdomen and the pump is filled with Baclofen.
The pump slowly injects Baclofen into the spinal canal. This treatment can reduce spasticity. An advantage is that it does not require cutting nerves or muscles. Disadvantages of the pump are the high rate of complications associated with The pumps must be maintained to work properly. Periodic visits are required to fill the pump with Baclofen and to adjust the dose of Baclofen the patient is receiving. Repeated surgeries are required periodically to replace the pump before the battery life is exhausted. Spasticity returns if the pump infusion is stopped.
Selective dorsal rhizotomy is a neurosurgical procedure that reduces lower extremity spasticity in patients with specific types a cerebal palsy. Our center has been performing selective dorsal rhizotomy since 1987. It is now clear that selective dorsal rhizotomy is an excellent option for many children and young adults with spastic cerebral palsy. For selective dorsal rhizotomy, an incision is made on the back. A small section of the back part of the bone is removed from the spine and the sensory nerves of the spinal canal are exposed. Each of the sensory nerves are tested to determine if it contributes to spasticity. Some of the nerves are cut.
Candidates for dorsal rhizotomy proceduresare those who have spastic diplegia, triplegia, hemiplegia, of quadriplegia. Secondary to premature birth or birth asphyxi. All should have potential for functional gain from dorsal rhizotomy The optimal age is two to five years but older children and young adults can also benefit from dorsal rhizotomy. What improvements can the patient expect from dorsal rhizotomy? Spasticity is reduced.
In patients with spastic deplegia, and hemiplegia spasticity is almost invariably reduced. Sometime spasticity is eliminated. Spasticity can be reduced permanently It's important to know that in patients with spastic quadriplegia, dorsal rhizotomy can sometimes fail to reduce spasticity. Sitting, crawling, standing, walking, transitional movements, and level of comfort will improve. The degree of improvement varies with individual patients depending on the age of the patient, the severity of the cerebal palsy, muscle strength and other factors.
Dorsal rhizotomy may reduce or eliminate the need for future orthopedic surgery. It is important to know that with patients who walk independently after dorsal rhizotomy, the chance for orthopedic surgery is very small. In contrast, in patients who walk with crutches or a walker or cannot walk at all, the chance for future orthopedic surgery is high. Even after dorsal rhizotomy. Dorsal rhizotomy can improve our movements in patients with spastic quadriplegia who have limited range of movements before surgery.
In patients who have a full range of arm movements before surgery, no improvement is noted. Dorsal rhizotomy does not improve fine motor skills in any patient In other centers, most often dorsal rhizotomy is performed after the bone is removed from a long five to seven levels of spine. Although children tend to do well even after this type of surgery, it is known that this type of procedure can result in spine problems even years after the surgery.
At our center, bone is removed from only a single level of spine. We developed this technique in 1991 and, since then, we have used this technique on all of our patients. We do not replace the bone In children the area will close with new bone Our dorsal rhizotomy procedure is less invasive than other procedures and has several important advantages.
The most important advantage is greatly reduced risk of future spine problems. In fact, we have seen only two spine problems in our patients since we started performing this procedure in 1991 Both children required surgery to correct the problem. We have further modified the dorsal rhizotomy surgical technique to reduce the risk of these problems in future patients. In our patients, there is minimal motor weakness for only a few weeks after surgery after other dorsal rhizotomy procedures, patients always show weakness for more than a few weeks. Patients recover rapidly after our dorsal resign amid procedures.
Regular vigorous physical therapy is resumed soon after surgery Dorsal rhizotomy is a complex procedure and carries risks. The major risks are paralysis of the legs, including permanent and complete paralysis, sensory loss in the legs, loss of bladder and bowel control, impotence in males and infection such as meningitis. The complications are, in general, apparent within a week after surgery. Other complications may include spinal fluid leak if spinal fluid leak occurs the leak site may need to be closed in the operating room.
The surgical technique has been further refined to decrease the risk of spinal fluid leak. Other minor risks are those associated with general anesthesia, pneumonia, wound infection and bladder infection after surgery If infection occurs, antibiotic treatment for one to two weeks is required. We are delighted that none of our patients have suffered any of the major neurological complications mentioned above A few patients had respiratory problems, pneumonia, wound infections and bladder infections. Patients are admitted to the hospital through the same day surgery unit on the day of surgery. They are discharged in the morning of the 5th day after the day of surgery. Hospitalization after dorsal rhizotomy, generally follows the protocol described in the following screens. Surgery takes two and a half to three hours.
For adult patients, surgery takes three-and-a-half to four hours. Parents and families are updated every hour during surgery. All painful procedures, including insertion of IV lines, insertion of EMG electrode wires and bladder catheter are done after the child is asleep. Patients leave the operating room with one IV line, an epidural catheter and a catheter in the bladder The stay in the recovery room is one to two hours after surgery. The patient is moved to the neuro surgery floor Pain management is a priority. Patients receive medications to control pain through the epidural catheter and muscle spasms through the IV Pain management is proven to be very successful with the epidural catheter. The Department of Anesthesiology pain service will monitor the pain medications that the patient receives On the first day after surgery the bladder catheter is removed.
In adult patients the catheter may be left in place somewhat longer Patients continue to receive pain medications infused through the epidural catheter for pain and IV muscle relaxers for muscle spasms. Patients are allowed to eat and drink is tolerated. Patients continue to be on bed rest IV fluids are continued to ensure adequate hydration On the third postoperative day, the epidural catheter is removed and oral pain medications and muscle relaxers are started. Patients eat and drink as tolerated but may continue to require IV fluids.
Patients begin limited physical therapy at the bedside in the morning patients and family members will be taught how to transfer the patient to a wheelchair. If they tolerated if not sitting in a wheelchair will be delayed until the afternoon therapy session. If the patient tolerates sitting in a wheelchair in the morning, the afternoon session will take place in the physical therapy department. Patients may have some difficulty with the first bowel movement. Medications such a stool softeners are given on postoperative day too.
As the problem is anticipated in all patients. If a bowel movement has not occurred by post-operative day three, patients may be given a suppository or an enema Physical therapy is provided twice on this day in the physical therapy department. Patients and family members are taught the postoperative home exercise program. The patients are encouraged to engage in as much movement as possible within their own comfort limits. This may include rolling, crawling, sitting and, for some patients, even standing in taking a few steps. Oral pain medicines are continued.
IV fluids are discontinued. On the fifth day after surgery, patients are discharged from the hospital. Patients will receive physical therapy once in the morning.
Patients and families will be given discharge instructions, the post-operative physical therapy protocol and other information to take to the physical therapist who will be treating the patient at home. Patients and families will receive a prescription for diazepam, a muscle relaxant. This should be picked up by a family member at the outpatient pharmacy on the first floor of the hospital Patients are recommended to use over-the-counter tylenol or ibuprofen as needed for pain. Travel by car or airplane are both possible on the day of discharge. Please remember that a recovery time is approximately two to three weeks after discharge. For adult patients the recovery may be somewhat longer. During this time some patients may appear weaker than before surgery. Strength will improve steadily.
Patients should resume physical therapy with local therapists. As soon as they return home, patients can be given a shower at any time. They can swim in the pool or play in the bathtub 10 days after surgery. Horseback riding is permitted in six weeks. Children may go back to school in two weeks.
We suggest they start school halftime and gradually increase school hours over the next week as they tolerate it. Depending on the type of work they do adult patients may return to work when they were able, but should stay home at least two weeks after discharge. Adult patients can resume driving when they're able to walk independently without an assistive device. It's important that patients be seen in our clinic after surgery The first appointment will be approximately four months after discharge from the hospital. This appointment is mandatory for patients residing in the US. We feel that this appointment is vital to the patient's well-being.
If the patient is unable to return for the post-operative appointment, the rhizotomy will not be considered. After he examines the patient Doctor Park will talk to the family about whether another appointment is necessary one year later. If another visit in a year is not necessary, Doctor Part will talk to the patient and family about follow-up by another physician near the patient's home. If at a later date the patient a family feel they would like to return for an appointment, that can always be arranged. Prescriptions for physical therapy, equipment and braces will be provided for only one year following the last appointment. If after examining the patient Doctor Park feels that another appointment when you later is in the best interest of the patient, guidance will be given to call the schedule that appointment in approximately nine months. During each follow-up appointment, Doctor Park and a physical therapist will examine the patient and discuss post-operative progress, patient family concerns and current needs.
The patient family will have the opportunity to ask questions regarding the frequency of physical therapy, equipment, and bracing recommendations All post-operative and follow-up examinations must be a hands-on evaluation in our clinic. Sending a video of the patient's motor function is not considered an adequate evaluation of the patient. A video will not take the place of either a post-operative or follow up appointment at the rhizotomy clinic. Thank you.
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